A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?
Coughing while eating.
Fine motor tremors.
Facial flushing.
Urinary incontinence.
The Correct Answer is A
Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.
Choice B is wrong because fine motor tremors are not related to speech or language problems.
They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.
Choice C is wrong because facial flushing is not related to speech or language problems.
It may be caused by high blood pressure, fever, anxiety or other conditions.
Choice D is wrong because urinary incontinence is not related to speech or language problems.
It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.
Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.
Pain is a common symptom of many conditions and injuries.
Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.
Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.
Petechiae are small red or purple spots on the skin caused by bleeding under the skin.
They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.
Correct Answer is B
Explanation
The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.
Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.
Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.
Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.
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